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Resident Agreement

DATE: ______________ RESIDENT NAME: ________________________________________________ NAME OF RESPONSIBLE PERSON: ______________________________________________________

DEFINITION OF TREATMENT

: The Inn on Barton Creek is an Assisted Living Facility (the “Facility”). TheFacility is not licensed for and will not provide medical or skilled nursing care.This agreement is between the Facility, the Resident, and the Responsible Person. The Facility agrees to rentapartment # _________ and to provide services outlined in this agreement. This Agreement if effective from ____/____/____ (date) until its revision or termination. This agreement supersedes any and all previous agreements.

SERVICES PROVIDED

: The Facility will provide the Resident with a Lifestyle Program based upon the specificneeds of the Resident as determined by the resident assessment. The Lifestyle Program may be changed at any time by the Facility as the Resident’s needs increase or decrease. The Resident and Responsible Person will be notifiedwithin 48 hours of a Lifestyle Program change.

ROOM AND BOARD

: The Resident and the Responsible Person agree to pay the following room and board feefor the rental of the specified apartment and services as outlined in this agreement:APARTMENT TYPE: ____________________________ DAILY RENT: __________________________ LIFESTYLE PROGRAM: _________________________ LIFESTYLE MONTHLY FEE: _____________ PERSONAL LAUNDRY SERVICES: [ ] Independent and Level 1 - $100 per month [ ] Family will provideOPTIONAL SERVICES: [ ] Covered Parking - $20 per month [ ] Telephone - $20 per monthESTIMATED MONTHLY TOTAL: ___________

The Lifestyle Program fee is subject to immediate change if the Resident’s needs increase or decrease2.If fees are increased for reasons other than a change in the Resident’s need for service, the Resident or Responsible Person will be given a 30 day written notice3.There will be no refund of any portion of a prepaid fee, except in the event of the death of the Resident. Paymentwill be calculated up to and including the date that all personal belongings are removed from the apartment4.There is a one-time, non-refundable $500.00 move-in fee, payable at the time of move-in to the Facility

The total monthly fee is due on the 1

day of each month. A $25.00 late fee will be charged if payment isreceived after the 10

of the month. A $25.00 fee will be charged for any checks returned for insufficient funds.

TERMINATION OF OCCUPANCY

:A. The Facility may upon thirty (30) days written notice to the Resident and the Responsible Party, discharge,transfer or evict the Resident for one of more of the following reasons:1.Non-payment for services within ten days of the due date

Failure of the Resident to comply with the state or local laws, or failure to comply with written policies or rules of the facility as outlined in the Resident Guide3.The resident poses a danger to self or others4.Inability of the Facility to meet the Resident’s needs5.Inability of the Resident to take life saving action in an emergency with the assistance of one person6.The resident wishes to transfer 7.A change in the use or ownership of the Facility, or it ceases to operateB. The Facility may require the Resident to vacate the Facility immediately by serving the Resident and theResponsible Person with a written notice if the Resident or someone in the Resident’s control is endangering themental and/or physical health or safety of himself/herself or others in the Facility, or is damaging or threateningimmediate damage to the Facility, or if the Resident’s medical emergency required immediate discharge or transfer.The cost of all repairs as a result of any damage caused by the Resident or someone in the Resident’s control will be paid by Resident and the Responsible Person within thirty (30) days after receipt of an itemized bill for repairsC. The notice shall include the reasons for the termination of occupancyD. The Resident agrees to give the Facility thirty (30) days written notice of intent to move from the Facility.Exceptions may be granted if the Resident’s condition prevents this from occurringE. The Resident agrees to give the Facility the right to show the Resident’s apartment to prospective Residents after written notice of intent to move is given by the Resident of the Facility

MISCELLANEOUS PROVISIONS

:A. The Resident agrees to cooperate with and abide by the general policies of the Facility that make it possible for the Residents to live together in a pleasant environment. A copy of the Facility’s Resident Guide will be provided tothe Resident. The Facility management reserves the right to make reasonable modifications to these policies as they judge necessary to enhance the quality of care, safety and lifestyle of all Residents. Notice of any additional policiesor changes shall be given to the Resident in writing.

I have reviewed and understand the general policies of the Facility as contained in the Resident Guide andagree to abide by them at all times. A copy of the Resident Guide has been given to me for my records

. __________ (Initials)B. The Resident has received a copy of the Notice of Privacy Practices for South Davis Community Hospital and/or affiliated providers, The Inn on Barton Creek, Orchard Cove, South Davis Home Health, and South Davis Hospice.

I have received a copy of the Privacy Notice for SDCH. __________

(Initials)C. The Facility makes every effort to provide a safe environment for all the Residents and their belongings.Personal effects (including but not limited to cash, clothing and jewelry) and furniture are not covered by theFacility’s insurance. The Facility recommends that these items be insured by the Resident for fire, theft, flood andearthquake.

I have reviewed and understand the Facility’s theft and loss policy and have read the above statementregarding insurance for my personal belongings

. __________ (Initials)D. The Resident may choose to allow the Facility to post Resident’s name outside apartment door and publishResident’s name and phone number in the Barton Creek Directory.

I give permission to the Facility to release my name and phone number for the Barton Creek Directory andpost my name outside my door.

__________ (Initials)E. No animals, birds or pets of any kind shall be permitted without written consent of the Facility management.F. The State Department of Health may examine Resident records as part of its evaluation of the FacilityG. The Facility management shall have a right to enter the Resident’s apartment in case of emergency, inspectionfor damage or repair, or delivery of legal noticesH. The Resident shall not redecorate or alter Resident’s apartment without the written permission of the FacilitymanagementI. In the event of an accident in which the Resident falls or is injured in any way and the Resident desires to havethe non-medical assistance of the Facility staff or a fellow Resident assist the Resident to his/her feet, to a chair or tothe Resident’s apartment at the specific verbal request of the Resident, then the Resident agrees to waive any and allliability claims against the Facility and the person or persons who provide such assistanceJ. The Resident hereby acknowledges that the Facility is not licensed for and does not provide medical or skillednursing care, and that it is the Facility’s policy to dial 911 on behalf of the resident in the event it appears to be tothe Resident’s benefit in the sole discretion of the Facility staff.K. The Resident hereby acknowledges that he/she has received a copy of the Resident’s Rights and has reviewedand understands these rightsL. This agreement is governed by the laws of the State of Utah. In the event any suit or action is brought to collectany fees or to enforce any provision of this Agreement, reasonable attorney’s fees and necessary costs shall beawarded by the trial and appellate courts to the prevailing parting in such suit or actionM. The Facility will monitor any and all care provided to the Resident by outside persons and agencies. Anyone providing care for the Resident will be required to inform the Office when they are seeing the Resident and mustleave a written report regarding the services provided with management when they have completed their visit. If services by an outside source do not meet the Facility’s standards, the Facility reserves the right to request that other care arrangements be made. All outside persons or agencies must supply the Facility with proof of a valid businesslicense, liability insurance and, if applicable, worker’s compensation insurance N. The Responsible Party agrees to assume responsibility for the Resident’s well-being as required by the StateDepartment of Health